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Thursday, July 14, 2011

At-home birth has pros and cons

At-home birth has pros and consThe number of at-home births is small but growing as pregnant women weigh the idea of a drug-free and surgery-free birth in a familiar setting versus the risk of harm to the baby in case of complications.By Olga Khazan

When mostpregnantwomen go into labor, they pack their bags for the hospital. When Lara Carlos felt the contractions in November 2008, she set up a birthing tub in her bedroom.For the next several hours, Carlos alternated between padding around her home and squatting and pushing in the tub. Her midwife poured water down her back and dabbed her forehead withcoldtowels. When the baby (they chose the name Vincent) arrived at 1:21 a.m., he spent his first few hours cuddling with his parents in their bed.

Carlos, who lives in Redlands, is one of a small but growing number of women who are choosing to deliver their babies at home. Her first son, Ivan, had been delivered in a hospital, and she says she found labor at home a dramatic improvement.

"In the hospital, there were seven medical students in the room when I was pushing my son out," she said. "At home, it was a very quiet, slow experience, and the water helped me to relax."

Though home births account for only about 1% of all births each year — 28,400 annually — they increased by 20% from 2004 to 2008 (the most recent available data), according to a May study in the journal Birth: Issues in Perinatal Care. The practice is most popular among well-educated mothers who favor natural childbirth without the drugs or surgeries a hospital might use.

"Women want to be able to say, 'I didn't think I could do it, but I did it for my baby,'" Carlos says. "They walk away feeling amazing, knowing that nobody did it but them."

The increase has reenergized the fierce debate over the safety of at-home delivery. The practice is officially frowned on by the American College of Obstetricians and Gynecologists, which issued an opinion in January saying it discourages home births because the absence of emergency medical equipment and specialists accustomed to dealing with complications means that problems during labor could cost the baby's life.

"All the existing scientific evidence, as well as state and national statistics, make it ultra-clear that home birth increases the risk of death," says Dr. Amy Tuteur, a Boston-based physician and former clinical instructor in obstetrics atHarvard Medical School who opposes home births. "What I had seen of it during my years of practice were only disasters."

The American College of Obstetricians and Gynecologists does acknowledge that home births are associated with fewer medical interventions than hospital births — a huge selling point for home-birth moms who want to experience a "natural" birth and avoid frequently administered drugs, such as Pitocin, which strengthens uterine contractions, and epidurals, which relieve pain when injected into the spinal canal. According to an April report by the Centers for Disease Control and Prevention, 61% of women who had vaginal delivery received an epidural in 2008, the year the report studied. And a 2006 national survey of women's childbearing experiences showed that 55% were given Pitocin to speed labor.

"There's no doubt that once you end up in a hospital, you end up with more interventions — that's what drives some families away," says Dr. Joseph Ouzounian, chief of obstetrics at Los Angeles County-USC Medical Center, who believes home birth is reasonable as long as women have few risk factors (such as health issues or being older than 35), have an emergency backup plan and understand the risks involved.

Women also turn to home birth in order to avoid caesarean sections, which have become more common as obstetricians became increasingly reluctant to take chances at the slightest sign of fetal distress. According to theCDC, caesareans now account for nearly one-third of hospital births in the United States — a much higher rate than most doctors say is ideal.

What's more, many hospitals do not allow women who have previously had a caesarean to attempt a vaginal birth because of the risk of uterine rupture, even though a 2010 National Institutes of Healthadvisory panel concluded that the risk of uterine rupture during a vaginal birth after one caesarean was just 1% and that more women should be offered the choice. Women wishing to have a VBAC (vaginal birth after caesarean) may have no option but to do so on their own turf.

Sarah Bolson of Covina had two caesareans but chose a home birth for her third pregnancy, successfully delivering a baby girl in January 2010.

"We had visited numerous hospitals, and the first time I mentioned a VBAC, I was just shut down completely," Bolson says. Doctors refused to consider it because of the chance of rupture, she recalls, and one said he couldn't risk having his medical malpractice insurance skyrocket.

She eventually found a certified professional midwife who was willing to help her deliver at home, with a backup plan of transfer to a nearby hospital. Though initially worried about complications, "after I was able to release the fear, I was free to birth without any inhibition."

Many home-birth moms also say they object to other aspects of hospital births, such as having to lie in a bed, abstain from food during labor and be monitored by an army of nurses.

"I believe in the intuitive power of the human body," said Mayim Bialik, an actress and natural-birth advocate who has given birth at home. "I believe in having as much privacy as possible, in being able to move freely, to eat when I want, drink when I want, and to be surrounded by the sounds and smells of what is familiar to me."

"Other mammals go off on their own to labor," adds Dr. Stuart Fischbein, a Los Angeles-based obstetrician who has been delivering exclusively in homes since 2010. "When a patient goes to a hospital, she gets told to lay flat on her back strapped down with monitors with constant interruptions from hospital personnel — does that sound conducive to having a normal labor?"

Arrangements for a home birth go something like this: Early in the pregnancy awoman finds either a certified nurse midwife (a registered nurse with advanced midwifery training) or a certified professional midwife (who is certified in attending out-of-hospital births but is not required to have a nursing degree). The midwife provides some or all of the woman's prenatal care and is on call as the woman approaches her due date. The expectant mom may also hire a doula, a non-medical professional who provides support during birth.

During labor, many women use water tubs because they find the water soothing and pain-relieving; others choose to just move about their homes as they see fit. The midwife monitors the fetus' heart tones with a Doppler device, and most also bring equipment such as oxygen tanks, anti-hemmorhagic medication, local anesthetic and suturing supplies in case of tearing orbleeding. If an emergency arises that the midwife can't manage, home-birth moms are advised to transfer immediately to a hospital.The core of the home-birth debate lies with the safety of the baby — and here, opinions and the data are sharply divided. A 2005 study of 5,418 births in the U.S. and Canada during 2000, published in the journal BMJ, found that the neonatal death rates of at-home births were comparable to those of births in hospitals.

But a July 2010 analysis published in the American Journal of Obstetrics & Gynecology examined the outcomes of 12 home-and-hospital-birth studies and found that babies born at home die at two to three times the rate of those born in hospitals, a finding largely responsible for the American College of Obstetricians and Gynecologists' position statement against home births.

The problem with home birth, Tuteur adds, is that the distance to the nearest emergency room can sometimes mean the difference between life and death. "Saying, 'trust birth' is like saying 'trust the weather,'" she says, referring to a slogan occasionally used in natural-birth groups.

Just as vocal online communities have sprung up to promote home birth, so too have others populated by women whose home-birth attempts turned into tragedies. In 2009, Austin, Texas, mom Liz Paparella's fourth child was stillborn on her living room couch because her midwife failed to take Paparella to the hospital when she began bleeding during labor.

"I never thought it was more dangerous to have a baby at home than at the hospital," says Paparella, who had given birth successfully at home two times previously. "In birth, the risk can change from low to high in a matter of minutes."

Much of the opposition to home births is directed at certified professional midwives, not nurse midwives. Critics say the certification for such professional midwives is inadequate for those without a prior nursing background. (Certified professional midwives counter that their training is as rigorous as that of nurse midwives and that their programs are specifically geared toward low-risk home delivery.)

A clear answer to the safety question is hard to find because nearly every home-birth study has some flaw that is flagged by one side of the debate or the other as invalidating the results. Given this uncertainty, Ouzounian cautions women to research, prepare and choose wisely.

Home births, he says, should be considered only by those who have a well-trained midwife and are experiencing no complications with their pregnancy (such as preeclampsia,gestational diabetes or preterm labor). They should be in good health (no immune deficiencies or chronic diseases) and should live within minutes of a hospital. Attempting a VBAC at home, as Bolson did, is also generally not advised.

"Under the right circumstances, with the right patient selection and with a certified nurse midwife attending, the overall maternal complication rates with home births are comparable" to those of a hospital birth, Ouzounian says.

But he also advises women not to think about birth in black-or-white terms: There are many ways to make delivery more "natural" even if it takes place in the hospital setting. Women who wish to give birth without epidurals, induction or C-sections should inform their obstetrician of their wishes in a written statement, early in their pregnancy, he says.

Fischbein says that doctors could be more accommodating to their patients by providing them with information about all of their birth options — at home and in the hospital — and stand ready to serve as backups for those who wish to labor at home with a midwife.

"There's room in this world for low-risk home birthing and for hospital birthing," he says. "We really should support each individual woman's right to choose how to deliver her baby."